Get the free Quitline FAX Referral Form - Kansas Department of ...

TEXAS TOBACCO QUIT LINE FAX REFERRAL FORM Fax Number: 18004833114 Provider Information:DATE FAX SENT PHA ZIP CODE PHA NAME PHA STAFF CONTACT NAME FAX NUMBER am a HIPAA covered entity (please check

How to fill out quitline fax referral form

How to fill out quitline fax referral form

1. To fill out the quitline fax referral form, follow these steps:
2. Obtain the quitline fax referral form from the appropriate source.
3. Open the form in a document editor or print a physical copy of the form.
4. Start by entering the date of referral and the patient's personal information, such as their name, date of birth, address, and contact details.
5. Fill in the referring healthcare provider's information, including their name, contact information, and any relevant identification numbers.
6. Provide details about the patient's tobacco usage, including the type of products used, frequency, and duration of use.
7. Enter any medical conditions or medications the patient may have that are relevant to their tobacco use.
8. Indicate the reason for the referral and any specific concerns or comments in the appropriate section.
9. Make sure to review the completed form for accuracy and completeness before submitting it.
10. If submitting electronically, follow the designated process for faxing the referral form. If submitting a physical copy, fax or deliver it to the designated recipient.
11. Keep a copy of the filled-out form for your records.

Who needs quitline fax referral form?

1. The quitline fax referral form is typically needed by healthcare providers or primary care physicians who want to refer their patients to a quitline program for assistance with tobacco cessation.
2. It is used to facilitate the transfer of patient information, allowing the quitline program to contact the patient and provide personalized support in quitting tobacco use.
3. Various healthcare professionals, including doctors, nurses, and counselors, may find the quitline fax referral form useful in ensuring their patients receive the necessary support and resources to quit smoking or using other tobacco products.

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What is quitline fax referral form?

Quitline fax referral form is a document used to refer individuals to a quitline service for help with quitting smoking or tobacco use.

Who is required to file quitline fax referral form?

Healthcare providers, counselors, or other professionals who are assisting individuals in quitting smoking or tobacco use may be required to file the quitline fax referral form.

How to fill out quitline fax referral form?

The quitline fax referral form typically requires information such as the individual's name, contact information, smoking history, and reason for referral. Professionals can fill out the form and fax it to the quitline service.

What is the purpose of quitline fax referral form?

The purpose of the quitline fax referral form is to connect individuals who want to quit smoking with resources and support offered by a quitline service.

What information must be reported on quitline fax referral form?

Information such as the individual's name, contact details, tobacco use history, and reason for referral must be reported on the quitline fax referral form.